Surgical Procedure with Retractor

ABSTRACT

A surgical retractor assembly is provided having a frame that releasably couples two retractor blades. The retractor blades are coupled to the frame via a pair of mobile carriages that engage a track on the frame. A third retractor blade is configured to be independent of the frame with the first two retractor blades. The independent blade may be fixably positionable in the patient by a direct coupling to a rigid table mount. The retractor assembly may be utilized for creating anterior access to spinal target site while the patient is oriented in the lateral decubitus position.

CROSS-REFERENCES

This application is a continuation of U.S. patent application Ser. No.16/273,386, which was filed Feb. 12, 2019, and which is a continuationof U.S. patent application Ser. No. 15/653,547, which was filed Jul. 19,2017. The contents of these applications are hereby incorporated hereinby reference in their entirety.

FIELD

The present disclosure relates to surgical access instruments andmethods for using them to perform surgical procedures on the spine.

BACKGROUND

The spine is critical in human physiology for mobility, support, andbalance. The spine protects the nerves of the spinal cord, which conveycommands from the brain to the rest of the body, and convey sensoryinformation from the nerves below the neck to the brain. Even minorspinal injuries can be debilitating to the patient, and major spinalinjuries can be catastrophic. The loss of the ability to bear weight orpermit flexibility can immobilize the patient. Even in less severecases, small irregularities in the spine can put pressure on the nervesconnected to the spinal cord, causing devastating pain and loss ofcoordination. Fusion is one method for treating the symptoms that canaccompany a damaged spinal disc, or other spinal pathologies that canresult in the impingement of neural structures. The primary goals offusion procedures are generally to reposition (e.g. increase spaceand/or alignment between vertebrae) portions of the spine, decompressingimpinged neural structures in the process, and to provide stability tomaintaining the position of those vertebrae. Most commonly, a fusionprocedure is performed by removing some or all of the disc materialbetween the vertebral segments to be fused and depositing one or moreinterbody spacers into the disc space. Over time new bone grows acrossthe disc space to provide a solid bridge between the vertebrae. As analternative to fusion, other motion preserving implants can also beimplanted in the disc space to reposition the vertebrae while stillmaintaining the ability of the vertebrae to move relative to each other.

In all of these procedures the ability to safely access the targetedportions of the spine and to effectively manipulate the instrumentationused to affect the work done on the spine is crucial to the success ofthe procedure. Traditionally, lumbar interbody fusion has been performedthrough procedures accessing the spine from the anterior (anteriorlumbar interbody fusion (ALIF)) or posterior, (posterior lumbarinterbody fusion (PLIF) and transforaminal lumbar interbody fusion(PLIF)) aspect of the patient. These procedures each present their ownadvantages and disadvantages. Posterior-access procedures, for example,involve traversing a shorter distance within the patient to establishthe operative corridor and can be augmented with posterior fixationwithout requiring the patient to be flipped during the surgery, albeitat the price of stripping away or cutting back muscles, and having toreduce or cut away part of the posterior bony structures (i.e. lamina,facets, spinous process) in order to reach the target site, andpresenting a relatively small access window within which to operate andadvance an implant through. On the other hand anterior-access proceduresdo not involve stripping or cutting back muscles, or reducing or cuttingaway bony structures to reach the surgical target site, and also presenta large access window, allowing for easier tool manipulation and theimplantation of a larger, more stable interbody implant. However, theyalso require traversing through a much greater distance within thepatient and mobilizing the abdominal contents, and sometimes thevascular structures running along the front of the spine, to establishthe operative corridor.

In the last decade, advances in technology and technique have also madea lateral approach to the spine a popular alternative to anterior andposterior approaches. The lateral approach achieves many of theadvantages of both the posterior and anterior approaches (e.g. avoidsstripping or cutting of back muscles, abdominal contents, and vascularstructures while presenting a large exposure through which a largeimplant can be advanced. On disadvantage with the lateral approachhowever is that the L5-S1 disc space, and sometimes the L4-L5 disc spacecannot not be accessed due to the presence of the iliac crest. Thus, inmany cases where multiple levels, including L5-S1 and/or L4-L5, are tobe fused, the surgeon must choose between using the lateral approach onthe upper level(s) and then flipping the patient in the middle of thesurgery to perform an ALIF on the lower level(s), or foregoing theadvantages that can accompany the lateral approach and doing each levelthrough an anterior approach in order to avoid flipping the patient. Theinstruments and methods described herein are directed towards providingadditional flexibility and options to the surgeon to eliminate, or atleast reduce, these and other challenges.

SUMMARY

The present disclosure describes a retractor assembly useful for formingan operative corridor to a target site at the spine of a patient. Theretractor assembly may be particularly useful in forming an operativecorridor to the lumbar spine from an anterior approach with the patientlying in the lateral decubitus position, for example, a Lateral ALIF.

The retractor assembly includes a main retractor and offset orindependent retractor set apart from the main retractor. The mainretractor has a frame, a first blade assembly, second blade assembly,and a pair of carriages that couple the blade assemblies to the frame.The offset retractor includes a third blade assembly. The frame extendsalong an arc between a pair of ends. In one example frame arc extendsapproximately 150 .degree. such that the frame has a crescent shape. Inthe same example, the diameter of the arc is approximately 9″. Thisconfiguration with the frame extending less than halfway around thecircle and the independent third blade is designed to maximize theamount of unencumbered perimeter surrounding the operative corridor,thus minimizing the interference with the surgeon's use of tools throughthe corridor and imaging.

A track runs along the frame and receives carriages that hold theretractor blade assemblies. The carriage adjustably couples the firstand second blade assemblies to the frame. The carriage has an unlockedconfiguration in which the carriage can translate along the track andthe orientation of the associated blade assembly can be adjustedrelative to the frame with 5 .degree. of freedom. The carriage also hasa locked configuration in which adjustment of the carriage position andblade orientation is inhibited.

The first blade assembly includes a blade post that couples to thecarriage and a fixed angle retractor blade. The first retractor blademay be a narrow blade and may be 18 mm wide according to one example.The first blade may include an anchor channel through which an anchormay be directed into the vertebral bone to fix the distal end of theblade relative to the bone. The second blade assembly includes a bladepost that couples to the carriage and an adjustable angle retractorblade. The second retractor blade may be a wide retractor blade, and maybe 25 mm wide according to one example. A pair of anchor channels passthrough the second blade through which anchors may be directed into thevertebral bone to fix the distal end of the blade relative to the bone.The second blade has an adjustment mechanism such that the angle of theblade relative to the post can be adjusted to add additional flexibilityto the overall positioning of the retractor assembly. While the firstblade is shown as a fixed and narrow blade and the second blade assemblyis shown as an adjustable and wide blade, it should be appreciated thatthe either or both of the first and second blades may be fixed oradjustable and wide or narrow. The third blade assembly includes a bladeextension and third blade. The blade extension connects to a rigid mountto secure the positon of the third retractor blade without the need forattaching the third blade to a frame. The third blade is shown as a wideblade and may be approximately 25 mm wide according to one example. Thethird blade may alternatively be a narrow blade. The third blade mayinclude a forward facing distal curve to engage against the side of thevertebral body.

In use, the retractor assembly is deployed to create and maintain anaccess or operative corridor to the spine of a patient. One exampletechnique for performing a Lateral ALIF procedure to the L5-S1 discspace with the retractor assembly positioning the patient on the tablein the lateral decubitus position. An oblique incision is made lateralto the rectus and cephalad to the inguinal ligament and an alternatingblunt scissor and finger dissection is used to enter the retroperitonealspace create a space through which the retractor blades may pass. Thesecond (lateral) blade is advanced through the retroperitoneal space andpositioned medial to the descending common iliac vessels and lateral tothe L5-S1 disc space with the distal end docked on the disc. The distalend of the blade may be anchored with a bone anchor through one of theanchor channels and into the S1 vertebral body. Next, the first(cranial) retractor blade may be guided down to the superior aspect ofthe disc space and below the descending vessel bifurcation. The distalend of the blade may be anchored with the placement of a bone anchorthrough the anchor channel into the L5 body. The frame may then beassembled with a pair of carriages loaded into the track. The frame isthen centered around the incision and a rigid table mount, for example,an A-arm mount may then be coupled to the frame. The first and secondretractor assemblies are then coupled to the frame by engaging them withtheir respective carriages. The position and orientation of thecarriage/blade may be adjusted in any of the 5 .degree. of freedom inorder to engage the post with the carriage. Once the blades are coupled,the carriages may be manipulated to their locked configuration. With themain retractor in place, the offset or independent retractor is placedin the medial position. The third (medial) blade may be advanced throughthe incision and positioned over the L5-S1 disc space. The third bladeassembly is then rigidly fixed in position by attaching to a rigid tablemount, by way of example, an A-arm table mount. Once access to the discspace is achieved has been achieved, the surgeon may proceed with discspace preparation and implant placement.

According to a first example, a retractor assembly is described formingan operative corridor to a spinal target site. The retractor assemblyincludes a main retractor assembly having a frame, a first mobilecarriage coupled to the frame and a first retractor blade assemblycoupled to the first mobile carriage. The main retractor also includes asecond mobile carriage coupled to the frame and a second retractor bladeassembly coupled to the second mobile carriage. An independent retractorassembly having a third retractor blade assembly that is directlycoupleable to a rigid mount is also included.

According to another aspect of the first example, the frame includestrack and the first mobile carriage and the second mobile carriagetranslate along the track.

According to another aspect of the first example, the track includes alower groove and an upper neck narrower than the lower groove.

According to another aspect of the first example, the first and secondmobile carriages each include a foot dimensioned to slide along thelower groove underneath the upper neck.

According to another aspect of the first example, the frame is arcuateand the track is arcuate extending from a first end to a second endalong the arcuate frame.

According to another aspect of the first example, the arcuate frameextends along an arc length of 150 .degree.

According to another aspect of the first example, the arc radius is 9inches.

According to another aspect of the first example, the track incudes anopening lacking the upper neck and the first and second carriage footsare inserted into the lower groove.

According to another aspect of the first example, the frame is made ofcarbon fiber. According to another aspect of the first example, theframe includes a connector site that is coupleable to a rigid mount.

According to another aspect of the first example, the first mobilecarriage and the second mobile carriage each have a locked configurationin which translation along the track is inhibited.

According to another aspect of the first example, each of the firstmobile carriage and second mobile carriage include an unlockedconfiguration in which the coupled blade assembly is adjustable withfive degrees of freedom.

According to another aspect of the first example, the first and secondcarriages each include a column extending upwards from the foot and abearing seat, blade holder, compression cap, and locking cap stackedatop one another along the column.

According to another aspect of the first example, the bearing seat has aspherical bearing surface and the blade holder has a spherical bearingsocket that bears on the spherical bearing surface.

According to another aspect of the first example, the upper surface ofthe blade holder is a spherical surface and the compression cap has aspherical under surface that bears on the upper surface of the bladeholder.

According to another aspect of the first example, the blade holderrotates about the spherical bearing surface of the bearing seat and therotational freedom of the blade holder defines an elliptic cone.

According to another aspect of the first example, the blade holderincludes a blade channel that receives a blade post of the first orsecond blade assembly.

According to another aspect of the first example, one of the first andsecond blade assemblies is a fixed assembly wherein the angle of theretractor blade is fixed relative to the blade post.

According to another aspect of the first example, one of the first andsecond blade assemblies is an adjustable assembly wherein the angle ofthe retractor blade relative to the blade post is adjustable.

According to a second example, a system for creating an anterior accesscorridor to a lumber spine with the patient in the lateral decubitusposition is provided. The system includes a three bladed retractorassembly. Two of the three retractor blades of the three bladedretractor assembly are coupled to an arcuate frame having an arc lengthof 180 .degree. or less. The third retractor blade is independent fromthe arcuate frame and is directly coupled to a rigid table mount to holdthe retractor blade in position.

According to another aspect of the second example, the two retractorblades coupled to the arcuate frame are each coupled to the frame by acarriage.

According to another aspect of the second example, each carriageincludes an unlocked position in which the associated retractor blade isadjustable with five degrees of freedom relative to the frame.

According to another aspect of the second example, the carriages aremovable along a track of the frame in the unlocked position.

According to another aspect of the second example, each carriageincludes a locked position in which movement along the track isarrested.

According to another aspect of the second example, the locked positioninhibits all movement of the associated retractor blade relative to theframe.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a retractor assembly configured for usein an anterior access surgery with the patient in the lateral decubitusposition, according to one example embodiment;

FIG. 2 is a perspective view of a main retractor assembly of theretractor assembly of FIG. 1;

FIG. 3 is a top side view of a frame forming part of the retractorassembly of FIG. 1;

FIG. 3a is a perspective cross-section view of the frame of FIG. 3;

FIG. 3b is another perspective view of a cross-section of the frame ofFIG. 3;

FIG. 4 is a perspective view of a carriage forming part of the retractorassembly of FIG. 1;

FIG. 5 is an exploded side view of the carriage of FIG. 4;

FIG. 5a is a cross-section view of the carriage of FIG. 5;

FIG. 6 is an exploded front view of the carriage of FIG. 4;

FIG. 6a is a cross-section view of the carriage of FIG. 6;

FIG. 7 is a side view of the carriage of FIG. 4 in an unlockedconfiguration;

FIG. 7a is a cross-section view of the carriage of FIG. 7;

FIG. 8 is a front view of the carriage of FIG. 4 with the carriage in anunlocked configuration;

FIG. 8a is a cross-section view of the carriage of FIG. 8;

FIG. 9 is a side view of the carriage of FIG. 4 in a lockedconfiguration;

FIG. 9a is a cross-section view of the carriage of FIG. 9;

FIG. 10 is a front view of the carriage of FIG. 4 with the carriage in alocked configuration;

FIG. 10a is a cross-section view of the carriage of FIG. 10;

FIG. 11 is a top view of the main retractor assembly of FIG. 2 with acarriage coupled to the frame and a retractor blade assembly with thecarriage in the locked position;

FIG. 11a is a cross section view of the main retractor assembly of FIG.11;

FIG. 12 is a perspective view of a first retractor blade assemblyforming part of the retractor assembly of FIG. 1;

FIG. 13 is a rear perspective view of a retractor blade of the firstretractor blade assembly of FIG. 12;

FIG. 14 is a side view of the retractor blade of FIG. 13;

FIG. 15 is a rear view of the retractor blade of FIG. 13;

FIG. 16 is a perspective view depicting a blade connector forming partof the first retractor blade assembly of FIG. 12;

FIG. 17 is a top view of the blade connector of FIG. 16;

FIG. 17a is a cross-section view of the blade connector of FIG. 17;

FIG. 18 is a front view of the blade connector of FIG. 16;

FIG. 19 is a side view of the distal end of the first blade assembly ofFIG. 12 including the blade connector and attached blade;

FIG. 19a is a cross-section view of the distal end of the first bladeassembly of FIG. 19;

FIG. 20 is perspective view of a second retractor blade assembly formingpart of the retractor assembly of FIG. 1;

FIG. 21 is a rear perspective view of a retractor blade of the secondretractor blade assembly of FIG. 20;

FIG. 22 is a side view of the retractor blade of FIG. 21;

FIG. 23 is a rear view of the retractor blade of FIG. 21;

FIG. 24 is a side view of a distal end of the second retractor bladeassembly of FIG. 20 with the blade connector and attached bladeangulated relative to a blade post;

FIG. 25 is a rear view of the distal end of the of the second retractorblade assembly of FIG. 20;

FIG. 26 is a side view of the distal end of the second retractor bladeassembly of FIG. 20;

FIG. 26a is a cross-section view of the distal end of the secondretractor blade assembly of FIG. 26;

FIG. 26b is another cross-section view of the distal end of the secondretractor blade assembly of FIG. 26;

FIG. 27 is a front view of the distal end of the second retractor bladeassembly of

FIG. 20;

FIG. 27a is a cross-section view of the distal end of the secondretractor blade assembly of FIG. 27;

FIG. 28 is a perspective view of a third retractor blade assemblyforming part of the retractor assembly of FIG. 1;

FIG. 29 is a rear perspective view of the retractor blade of FIG. 28;

FIG. 30 is a side view of the retractor blade of FIG. 28;

FIG. 31 is a rear view of the retractor blade of FIG. 28;

FIG. 32 is a top view of the retractor blade of FIG. 28;

FIG. 33 is a perspective view of a blade extension forming part of thethird blade assembly of FIG. 28;

FIG. 34 is a side view of the third blade assembly of FIG. 28 formingpart of the retractor assembly of FIG. 1;

FIG. 35 is an exploded perspective view of the third blade assembly ofFIG. 34 with a mount coupler separated from a connector of the bladeassembly;

FIG. 35a is a cross-section view of a proximal end of the third bladeassembly of FIG. 34;

FIG. 36 is a side view of the coupler of FIG. 34 shown in an unlockedconfiguration;

FIG. 36a is a cross-section view of the coupler of FIG. 36;

FIG. 37 is a front view of the coupler of FIG. 34 shown in an unlockedconfiguration;

FIG. 37a is a cross-section view of the coupler of FIG. 37;

FIG. 38 is a side view of the coupler of FIG. 34 shown in a lockedconfiguration;

FIG. 38a is a cross-section view of the coupler of FIG. 38;

FIG. 39 is a front view of the coupler of FIG. 34 shown in a lockedconfiguration;

FIG. 39a is a cross-section view of the coupler of FIG. 39;

FIG. 40 is a top view of the retractor assembly of FIG. 1;

FIG. 41 is a perspective view of the retractor assembly of FIG. 1;

FIGS. 42-45 are illustrative images depicting example steps according toone exemplary method of utilizing the retractor assembly of FIG. 1 toperform a Lateral ALIF procedure at the L5-S1 disc of the lumbar spine.

FIG. 46 is an exploded perspective view of a retractor assemblyaccording to a second example embodiment configured for use in ananterior access surgery with the patient in the supine position,according to one example embodiment; and

FIG. 47 is a perspective view of the retractor assembly of FIG. 46.

DETAILED DESCRIPTION

Illustrative embodiments of a surgical retractor assembly are describedbelow. In the interest of clarity, not all features of an actualimplementation are described in this specification.

It will of course be appreciated that in the development of any suchactual embodiment, numerous implementation-specific decisions must bemade to achieve the developers' specific goals, such as a compliancewith system-related and business-related constraints, which will varyfrom one implementation to another. Moreover, it will be appreciatedthat such a development effort might be complex and time-consuming, butwould nevertheless be a routine undertaking for those of ordinary skillin the art having the benefit of this disclosure. The retractor assemblyand methods of using the retractor assembly disclosed herein boasts avariety of inventive features and components that warrant patentprotection, both individually and in combination.

An illustrative embodiment of a retractor assembly 2 is shown in FIG. 1.The retractor assembly 2 is depicted in configuration for performing ananterior approach to the spine with the patient lying in the lateraldecubitus position. For expediency, this may be referred to herein asthe Lateral ALIF approach or Lateral ALIF configuration, however, itshould be appreciated that surgeries other than fusion (e.g. artificialdisc replacement, corpectomy) may similarly be performed through theaccess corridor created. The approach shown in FIG. 1 is to the L5-S1disc space. The retractor assembly 2 includes a main retractor 4 andoffset retractor 6 set independent from the main retractor. The mainretractor 4, shown in FIG. 2, has a frame 8, a first blade assembly 10,second blade assembly 12, and a pair of carriages 16 that couple theblade assemblies to the frame. The offset retractor 6 includes a thirdblade assembly 14. According to the example Lateral ALIF configurationshown, the first blade assembly may be positioned as the cranial blade,the second blade assembly as the lateral blade, and the third bladeassembly as the midline blade.

With reference to FIG. 3, the frame 8 has an upper surface 18, lowersurface 20, and extends along an arc between a pair of ends 22. In theexample embodiment shown the frame arc extends approximately 150.degree. such that the frame has a crescent shape and a diameter ofapproximately 9″. Together with the minimalist profile of the offsetretractor 6, this crescent frame 8 provides flexibility to the surgeonwhile operating through the retractor (e.g. performing a discectomy orplacing an implant) as it minimizes encumbrances on ability to freelymanipulate the instruments used during the procedure. It is contemplatedthat the arc may in some embodiments depart from the arc of a circle,for example, the arc could also be the arc of an ellipse or an oval. Itis further contemplated that the frame 8 may define an arc length ofgreater than 150 .degree. or less than 150 .degree. and a diameter ofgreater than 9″ or less than 9″. By way of example, the arc may extendfrom 90 .degree.-180 .degree. and the diameter may range between 6″ and12″. According to a preferred example, the frame 8 may also beconstructed of carbon fiber or other composite materials to minimizeinterference with flourovisibility.

A track 24 runs along the frame between the pair of ends 22. The track24 is open to the upper surface 18 and includes a distal groove 26 and aproximal neck 28 that is narrower than the distal groove. The proximalneck 28 is formed by a pair of ledges 30 that extend over the distalgroove 26 as best viewed in FIG. 3a . An opening 32 is situated on thetrack 24 and is marked by the absence of ledges 30 such that thecarriages 16 are top loaded onto the track through the opening 32.Carriage markers 33 may be included on the frame to help with initialset up of the retractor 4. That is, the markers 33 mark the generalpositions in which the carriages 16 will rest along the frame whenutilized for a Lateral ALIF procedure. The carriages 16 may bepre-loaded to those positions such that only minimally adjustment islater needed in order to couple the first and second blade assemblies10, 12. A connector 34 (e.g. the poker chip connector shown) is situatedon the frame 8 and may be attached to a rigid mount (e.g. an A-arm tablemount) to fix the position of the frame 8. Some alternate embodiments ofthe frame 8 may have more than one track 24 covering subsets of thedistance between the ends 22. For example, shorter distinct tracks couldbe provided for to each receive an individual carriage.

An example embodiment of the carriage 16 is illustrated in FIGS. 6-10.The carriage 16 serves to adjustably couple the first and second bladeassemblies 10, 12 to the frame 8. Carriage 16 has an unlockedconfiguration (FIGS. 7-8) in which the carriage can translate along thetrack 24 to adjust the position of the carriage on the frame 8 and theorientation of the blade assembly, 12, 14 can be adjusted relative tothe frame. In the locked configuration (FIGS. 9-10) adjustment of thecarriage position and blade orientation is prohibited. The embodiment ofthe carriage 16 shown allows the blade assembly 12, 14 to move with fivedegrees of freedom (translation in two dimensions as well as yaw, pitch,and roll rotational motion) relative to the frame 8. For the purposes ofthis discussion, yaw refers to rotation about the distal/proximal axisof the carriage; pitch refers to rotation about an axis parallel to atangent to the frame 8 at the location of the carriage 16; and rollrefers to rotation about an axis that intersects the frame 8 at thelocation of the carriage 16 and the center of the circle generallydefined by the frame 8.

The foundation of the carriage 16 is a column 36. The column 36 includesa foot 38 at the distal end opposite a proximal head 40. A shaft 43extends between the foot 38 and the head 40 and mounted on the shaft 43is a bearing seat 44. The head 40 is threaded externally with a reversethread and also includes an internal thread 42. Adjacent the head 44,the shaft has a neck 37 that includes at least one flat surface. Thebearing seat 44 includes a spheroidal body 45 with an upper sphericalbearing surface 46, a base 47 with a lower friction surface 48, and acentral passage 49 which is received about the shaft 43. The centralpassage 49 is keyed to a longitudinal groove 50 extending along aportion of the shaft length inhibiting rotation of the bearing seat 44about the shaft while permitting longitudinal translation of the seat 44up the shaft to the extent of the groove 50. The base 48 frictionallyengages the upper surface 18 of the frame 8 when the carriage is loadedin the track 24 and the lower friction surface 48 may be roughened orinclude teeth, ridges, or other friction enhancing features.

The foot 38 is configured to engage the track 24 of frame 8. The maximumwidth and height of the foot 38 are configured such that the foot can beslidably received in the distal groove 26 of track 24 with the ledges 30of the proximal neck 28 extending over the foot 38 such that the foot isvertically constrained in the track 24, as best viewed in FIG. 11a . Thefoot 38 is generally peanut shaped having a length greater than thewidth and a pair of bulbous ends curving into a narrower center. Apedestal 39 seated on top of foot slides through the neck when the footis engaged in track 24. The track opening 32 is sized to allow the foot38 to enter and engage the groove 26 underneath the neck 28. The peanutshape allows the foot to translate along the arced track 24 withoutbinding while also preventing rotation of the foot 38 within the track24. As such, the same side of the carriage 16 always faces the center ofthe circle defined by the frame 8. Assuming that the incision isapproximately in the center of the circle defined by the frame, such aconfiguration has the advantage of keeping a retractor blades orientedtoward the incision while the carriages 16 translate along the track 24.

Stacked atop the bearing seat 44, one on top of the other along thecolumn 36, the carriage 16 further includes a blade holder 52,compression cap 72, and locking cap 88. The blade holder 52 is dividedinto an upper arm 54 and a lower arm 56 that are separated by a notch 58that permits flex between the upper and lower arms, the notch opening onone side of the blade holder and extending to a sidewall 59 on theopposite side. The notch opening opposite the sidewall widens to a bladechannel 60 dimensioned to receive a blade post of a retractor bladeassembly. Tapered ends cause the upper and lower arms 54, 56 to flexapart as the blade post is pressed into the blade channel 60.Compression stops 62 situated adjacent the blade channel prevent overcompression of the upper and lower arms. The under surface of the bladeholder 52 has first bearing socket 66 that receives and mates with thebearing seat 44 spherical bearing surface 49 with the column shaft 43passing through a central passage 64. The central passage 64 has anelliptic cone shape extending upward from the first bearing socket thatallows the blade holder to rotate around the shaft 43 on the bearingseat 44. By way of example, the elliptic cone is dimensioned such thatthe blade holder can rotate 30 .degree. in the front to back direction(i.e. in line with blade channel 60) and 15 .degree. in the side to sidedirection. The upper surface 68 of the blade holder is spherical and maybe roughed to increase locking friction with the compression cap 72.

The compression cap 72 has a spherical under surface 74 against whichthe upper surface of the compression cap 72 rotates. The lower surface74 may also be roughened to increase locking friction with the uppersurface 68 of the blade holder. A lower spring cavity 76 sits above thespherical under surface 74 and is bounded by an outer wall 78. Centerpassage 80 connects the lower spring cavity 76 and under surface 74 andincludes at least one flat surface to engage with flat surface 37 of thecolumn neck and prevent rotation of the compression cap around thecolumn 36.

The locking cap 88 has an outer cup 90 fixed to a drive nut 92. By wayof example, the cup is fixed to the drive nut by pins 94 that extendinto apertures in the drive nut. A distal wall 95 of the drive nut 92surrounds an upper spring cavity 98 and extends into the outer cuphollow defining a gap 96 between the outer cup 90 and the drive 92. Thegap 96 is dimensioned to receive the compression cap outer wall 78 asthe locking cap advances toward the compression cap to lock the carriage16. A superior cavity 104 is situated in the locking nut 92 and isseparated from the upper spring cavity by an internally threaded passage100. The internal thread of passage 100 mates with the exterior threadof column head 40 to advance the locking cap up and down along thecolumn 36 as the locking cap is rotated. A handle 106 is coupled to thelocking nut 92 by a pivot such that it can be rotated out of the way ifnecessary once the carriage is locked. A set screw 102 threadedlyengages the internal threading 42 on the column head to fix the carriagecomponents together. The head of the set screw 102 resides in thesuperior cavity 104 to define the upper and lower limits of the lock nuttravel relative to the column 16. A thrust bearing 82, bearing cap 84,and return spring 86 are housing in the upper and lower spring cavitiesto tension the compression cap 72 against the blade holder 52 when thecarriage is unlocked.

In use, carriages 16 are coupled to the frame 8 while in the unlockedconfiguration. The foot 38 is advanced into the opening 32. An upwardforce is applied to the compression cap 72, compressing the returnspring 86 and pushing the compression cap 72 up into the locking cap 86with the outer wall 78 sliding into gap 96. This provides space for theblade holder 52 to rise proximally relative to the foot 38, which inturn provides space for the bearing seat 44 to rise proximally relativeto the foot 38 such that the bearing seat base 47 clears the track neck28, allowing the foot 30 to be advanced into the distal groove 26 of thetrack 24. The upward force may be applied to the compression cap 72 byholding the locking cap 88 and lifting up on the blade holder 52. Oncethe carriage 16 is advanced to the desired position along the track andthe upward force is removed, the return spring 86 redirects thecompression cap 72, blade holder 52, and bearing seat 44 downward suchthat the friction surface 48 of the base 47 works against the uppersurface 18 of the track 24 to hold the carriage in place. With thecarriages 16 coupled to the frame 8, the first and second bladeassemblies 10, 12 are attached by side loading the blade posts 108, 150into the respective blade channels 60 of the blade holder 52.

With the blade assemblies 10, 12 coupled to the blade holders 52, theretractor blades can be adjusted through 5 degrees of freedom relativeto the frame 8 to precisely position the blades in the proper locationand orientation. In the present example the 5 degrees of freedom areyaw, pitch, roll, surge, and sway, with yaw being rotation about thez-axis, pitch being rotation about the y-axis, roll being rotation aboutthe x-axis, surge being translation along the x-axis, and sway beingtranslation along the y-axis. Yaw, pitch, and roll are achieved viarotation of the blade holder 52 about the column as described above.Surge is achieved via translation of the blade post 108 through theblade channel 60 and sway is achieved via translation of the carriage 60along the track 24. Additional roll may be achieved by rotation of theblade post 108 about its own longitudinal axis in the blade channel 60.

Once the blade assemblies 10, 12, coupled to the carriage and positionedas desired, the carriages 16 can be locked to inhibit further movementof the carriage and blade. To lock the carriage, the handle 106 isrotated to rotate the drive nut 92 and advance the internal threadsdistally along the column external threads. This advances the outer cupdown along the compression cap until the outer wall is situated in thegaps, eliminating the space for the compression cap to move proximally.The compression cap presses the blade holder 52 and bearing seatdistally. The blade holder is compressed between the compression cap andbearing seat and the friction between the components locks orientationof the blade holder. The upper and lower arms of the blade holder arealso compressed around the blade post elimination the ability for theblade post to translate in the blade channel. The friction between thebearing seat base and the upper surface of the frame eliminates theability for the carriage to translate along the track.

FIGS. 12-19 a illustrate an example embodiment of the first bladeassembly 10. The first blade assembly 10 includes a cylindrical bladepost 10, a handle 110, blade connector 112 and first blade 114. Thehandle 114 provides a grip for manually holding, placing, andmanipulating the first blade assembly 10. The post 108 has a diameterconfigured to be received in the blade channel 60 of the blade holder 52and such that the blade post can be translated along its axis and/orrotated about its axis within the blade channel 60 until the upper andlower arms 54, 56 of the blade holder 52 squeeze against the post 108when the carriage 16 is locked. Referencing FIGS. 12-15, the first blade114 includes a distal end 116, an intermediate portion 118, and aproximal end 120. Between the proximal end and distal end on one side isa rear face 117 that is generally smooth and configured to engage bodytissue surrounding the operative corridor. The distal end 116 is curvedtowards the rear and may have a slight concave end surface to lieagainst the curved surface of the vertebra and hold tissue back at thetarget site. An anchor channel 132 passes through the midline of theblade 114 adjacent the inner face 119. An anchor, such as a pin or screw(not shown) can be passed through the blade to secure the positon of theblade relative to the spine and prevent blade shift should the patientor retractor be inadvertently jostled.

The proximal end of the blade 120 has an attachment feature 122configured to engage and couple with the blade connector 112. Theattachment feature 122 is in the form a vertical bar 124 extendingrearward from a back wall 121 with a pair of narrow wings 126 extendinghorizontally along the midsection of the bar 124. The wings 126 do nothave the same depth as the bar 124 such that there is a gap between eachwing and the back wall 121. Each wing 126 has a tapered leading edge 128of and a flat trailing edge 130.

As shown in FIGS. 16-17 a, the blade connector 112 is configured toreceive attachment the feature 122 of blade 114 to rigidly couple theblade to the assembly 10. The connector includes a housing 134 thatdefines a receptacle 136 that will receive the attachment feature 122.The receptacle 136 is T-shaped with a rear slot dimensioned to receivethe wings 126 and a narrow neck dimensioned to receive only the verticalbar 124 such that the wings 126 are captured within the slot. A pair oflocking arms 138 are coupled to the housing 134 at a pivot 140. Alocking head 142 of the locking arm 138 extends into the slot. Thelocking head has a tapered upper surface 144 and a flat lower surface146. A spring 148 biases the locking arm in a locked position with thelocking head extending into the receptacle slot. To couple the blade114, the attachment feature is simply aligned with the receptacle andadvanced. The tapered leading edges of wings 126 engaged the taperedupper surfaces 144 of the locking heads 142 causing the arms to swingoutwards and allowing the wings to pass. Once the wings 126 pass thelocking heads 142, the locking heads return to their biased lockingposition where the flat lower surfaces 146 engage the flat trailingsurfaces of the wings 126 preventing their removal, as depicted in FIG.19a . To remove the blade 114 the locking arms are depressed to swingthe locking heads 142 out of the receptacle and the blade 114 is simplylifted out.

FIGS. 20-27 a illustrate an example embodiment of the second bladeassembly 12. The second blade assembly 12 includes a cylindrical bladepost 150, a handle 152, blade connector 154 and second blade 156. Thehandle 152 provides a grip for manually holding, placing, andmanipulating the second blade assembly 12. The post 150 has a diameterconfigured to be received in the blade channel 60 of the blade holder 52and such that the blade post can be translated along its axis and/orrotated about its axis within the blade channel 60 until the upper andlower arms 54, 56 of the blade holder 52 squeeze against the post 150when the carriage 16 is locked. Referencing FIGS. 20-23, the secondblade 156 includes a distal end 158, an intermediate portion 160, and aproximal end 162. Between the proximal end and distal end on one side isa rear face 166 that is generally smooth and configured to engage bodytissue surrounding the operative corridor. The distal end 158 is curvedtowards the rear and may have a slight concave end surface to lieagainst the curved surface of the vertebra and hold tissue back at thetarget site. A pair of anchor channels 164 pass through the second blade156 adjacent the inner face 163. The anchor channels 164 are situatedalong the sides of the blade and may slightly converge in the distaldirection to increase stability of the anchorage. Anchors, such as apins or screws (not shown) can be passed through the anchor channels 164to secure the positon of the blade relative to the spine and preventblade shift should the patient or retractor be inadvertently jostled. Acenter slot 165 on the inner face 163 may be included to interface withother tools that may be inserted into the access corridor, such as, forexample, a light cable (not shown).

The proximal end of the blade 162 has an attachment feature 168configured to engage and couple with the blade connector 154. Theattachment feature 168 is in the form a vertical bar 170 extendingrearward from a back wall 161 with a pair of narrow wings 172 extendinghorizontally along the midsection of the bar 170. The wings 172 do nothave the same depth as the bar 170 such that there is a gap between eachwing and the back wall 161. Each wing 172 has a tapered leading edge 174of and a flat trailing edge 176.

As shown in FIGS. 16-17 a, the blade connector 154 has an attachmenthousing 178 configured to receive attachment the feature 168 of thesecond blade 156 to rigidly couple the blade to the assembly 12. Theblade connector 154 also includes a tilt housing 193 that may beoperated to angulate the 156 blade relative to the post 150. Theattachment housing 178 defines a receptacle 180 that will receive theattachment feature 168. The receptacle 180 is T-shaped with a rear slotdimensioned to receive the wings 172 and a narrow neck dimensioned toreceive only the vertical bar 170 such that the wings 172 are capturedwithin the slot. A pair of locking arms 182 are coupled to the housing178 at a pivot 184. A locking head 186 of the locking arm 182 extendsinto the slot. The locking head has a tapered upper surface 188 and aflat lower surface 190. A spring 192 biases the locking arm in a lockedposition with the locking head extending into the receptacle slot. Tocouple the blade 156, the attachment feature 168 is simply aligned withthe receptacle 180 and advanced. The tapered leading edges 174 of wings172 engaged the tapered upper surfaces 188 of the locking heads 186causing the arms to swing outwards and allowing the wings 172 to pass.Once the wings 172 pass the locking heads 186, the locking heads returnto their biased locking position where the flat lower surfaces 190engage the flat trailing surfaces 176 of the wings 172 preventing theirremoval, as depicted in FIG. 26a . To remove the blade 156 the lockingarms are depressed to swing the locking heads 186 out of the receptacleand the blade 156 is simply lifted out.

Referring to FIGS. 25 and 26 a, the tilt housing 193 sits behind theattachment housing 178 and couples to the post 154 such that the bladeconnector can angulate relative to the post 150. To do so the post 150includes a pair of clamping arms 194 separated by a notch. The arms 194end in circular clamping elements 196 separated by a space. An innerdisc 200 extending from the back of the attachment housing 154 issituated between the clamping elements 196. Inner surfaces of theclamping elements and the outer surfaces of the inner disc 200 areridged or scalloped to provide a secure and rigid connection when theblade angle is locked. An axel 198 passes through the a center hole ineach of the clamping elements 196 and inner disc 200 to couple the armsto the connector 154 and provide a pivot about which the blade connectorrotates. A rear opening 210 in the tilt housing 193 allows the blade torotate through a full range of motion up to 90 .degree. An upper openinghouses a lock nut 202 that is coupled to the housing opening such thatit rotates but does not translate relative to the housing. The lockingnut 202 is threadedly coupled to a shaft 204 that passes through athreaded inner aperture in the locking nut. The shaft 204 is coupled toa locking press 206 with fingers 208 that fit around the clampingelements 193. The ends of the fingers 208 are tapered and complementtapered edges of the clamping elements 196. When the shaft 204 is fullyraised into the locking nut 202 the locking press 206 allows theclamping elements rest in their open state such that the ridges on theclamping elements and inner disc 200 do not engage and the disc 200,along with the blade connector 154 and blade 156, can rotate relative tothe clamping element 193 and post 150. When the locking nut 202 isrotated the shaft 204 is lowered into the housing and the locking pressfingers 208 engage the sides of the clamping elements 196 squeezing themtogether to engage the ridges on the clamping elements 196 with those onthe inner disc 200, locking the angular position of the blade.

In the present example, the first blade assembly 10 has been shown as afixed blade and the second blade assembly 12 has been shown as anadjustable blade. However, it should be appreciated that position of thefirst blade assembly 10 and the second blade assembly 12 may be swappedon the retractor frame 8 from that shown herein. Alternatively, both thefirst retractor assembly and the second retractor assembly may use afixed assembly like that shown in FIGS. 12-23, or, each of the firstblade assembly and the second blade assembly may use an adjustableassembly like that shown in FIGS. 24-27 a, depending on the patient'sanatomy and the surgeon's needs or preferences. The adjustable assemblyprovides additional flexibility to the retractor while the rigidassembly provides a lower profile. Similarly, the narrow blade 114depicted with first blade assembly 10 and the wider blade 156 depictedwith second blade assembly 12 may also be swapped and used in any of theabove combination as well.

FIGS. 28-34 illustrate, by way of example, the third blade assembly 14and FIGS. 35-39 a depict the coupler 260 that connects the third bladeassembly to a rigid mount. The third blade assembly 14 includes bladeextension 212 and third blade 214. The blade extension includes a shaft216, mount connector 218, and blade connector 228. Referring to FIGS.33-35, the mount connector 218 includes a “poker chip” face with ridgesand a female receptacle. Within the receptacle 222 is a circumferentialgroove 224 and a screw 226 that attaches the connector to the shaft 216.

The third retractor blade is depicted, by way of example, in FIGS.28-32. The third blade 214 includes a distal end 230, an intermediateportion 232, and a proximal end 234. Between the proximal end and distalend on one side is a rear face 240 that is generally smooth andconfigured to engage body tissue surrounding the operative corridor andon the opposite side is inner face 236. The distal end 230 is curved andthe profile reduced on the rear face to create a saddle. The curveprojects away from the rear such that it creates a forward hook at thedistal end 230. This forward hooks scoops around the side of thevertebra and creates leverage to better hold the blade in position. Acenter slot 238 on the inner face 236 may be included to interface withother tools that may be inserted into the access corridor, such as, forexample, a light cable (not shown). The proximal end of the blade 234has an attachment feature 242 configured to engage and couple with theblade connector 228. The attachment feature 242 is in the form avertical bar 244 extending rearward from a back wall 241 with a pair ofnarrow wings 246 extending horizontally along the midsection of the bar244. The wings 246 do not have the same depth as the bar 244 such thatthere is a gap between each wing and the back wall 241. Each wing 246has a tapered leading edge 248 of and a flat trailing edge 250.

The attachment housing 252 defines a receptacle 254 that will receivethe attachment feature 242. The receptacle 254 is T-shaped with a rearslot dimensioned to receive the wings 246 and a narrow neck dimensionedto receive only the vertical bar 244 such that the wings 246 arecaptured within the slot. A pair of locking arms 256 are coupled to thehousing 252 at a pivot 258. A locking head (not shown) of the lockingarm 252 extends into the slot. The locking head has a tapered uppersurface and a flat lower surface and is spring biased to a lockedposition with the locking head extending into the receptacle slot. Tocouple the blade 214, the attachment feature 242 is simply aligned withthe receptacle 254 and advanced. The tapered leading edges of wings 248engaged the tapered upper surfaces of the locking heads causing the armsto swing outwards and allowing the wings 246 to pass. Once the wings 246pass the locking heads, the locking heads return to their biased lockingposition where the flat lower surfaces engage the flat trailing surfaces250 of the wings 246 preventing their removal. To remove the blade 214the locking arms are depressed to swing the locking heads out of thereceptacle and the blade 214 is simply lifted out. The attachmenthousing is set at an angle relative to the shaft 116 such that the anglebetween the third blade 214 and the shaft 216 is greater than 90.degree. By way of example, the angle of the housing is set such thatthe blade angle is 100 .degree. This angle provides extra clearance forthe surgeon to get a hand between the patient and the shaft in order tomanipulate the blade assembly 14 better.

The coupler 260 engages the mount connector 218 is rigidly attached to arigid mount, such as, an articulating arm table mount or A-arm (notshown) at one end and attaches to the mount connector 218 of the thirdblade assembly 14 at the other end. The mount 260 has a housing 262 witha “poker chip” face 264 on one end that complements and engages the“poker chip” face of the mount connector 218. A hollow cylinder 266extends through the face 264 and includes a series of circular apertures268 arrayed around and end of the cylinder and one or more balls 270aligned with the apertures. A plunger 272 extends through the cylinder266 and is coupled to piston 282. The distal end 274 of the plunger hasan enlarged head that sits beyond the end of the cylinder 266 and isseparated from the cylinder by a series of bellville washers 278 thatprovide a spring force to the plunger. The shaft 276 of the plunger 272includes detents 280 that align with the balls 270 when the coupler isin the unlocked position. This allows the balls 270 to retreat into theapertures 268. In the locked position the shaft 276 forces the balls 270to partially extend out of the apertures 268. To move the couplerbetween the locked and unlocked positions, the plunger is connector tothe piston 282 which is coupled to a lever 284. The lever connects tothe housing 262 at a pivot point via pivot pins 286. Above the pivotpins the housing includes a translation slot that houses a translationbar 294 that slides up and down the slot. Ends of the translation bar294 are situated in arcuate tracks 288 on the sides of the lever. Afirst end 290 of the arcuate track is situated closer to the pivot pointthan a second end 292 such that as the lever rotates around the pivot,the translation bar 294 moves up or down moving the piston along withit. To couple the third blade assembly 14 to the coupler 260, theplunger 272 and cylinder 266 are inserted into the female receptacle 222on the mount connector 218 with the lever in the unlocked positon suchthat the plunger 271 is extended. The lever 284 is rotated to the lockedposition drawing the plunger 272 into the cylinder 266 allowing the“poker chip” faces to engage and forcing the balls 270 through theapertures where they engage with the circumferential groove 224 to lockthe coupler 260 and connector 218 together. A rigid extension arm 296 ofthe coupler extends away from the housing 262 and includes an adapter,which may be threading or other suitable feature, which connects thecoupler to the table mount (not shown).

In use, the retractor assembly 2 is deployed to create and maintain anaccess or operative corridor to the spine of a patient. By way ofexample, the retractor assembly 2, as configured and described above isparticularly well suited for creating an access corridor to the spinefrom an anterior approach (e.g. ALIF), and even more particularly ananterior approach performed with the patient situated in the lateraldecubitus position (e.g. Lateral ALIF). For example, as illustrated inFIGS. 40-41, a final configuration for performing a Lateral ALIF mayinclude just three retractor blades, rather than the four or moreretractor blades typically used for an ALIF approach. This reduction inblade count helps facilitate imaging of the surgical site (e.g. viafluoroscopy) and manipulation of instrumentation through the operativecorridor because there is less material around the access corridor toprovide obstruction Likewise, utilizing and independently fixed thirdblade assembly, rather than coupling the third blade to the framereduces the frame length needed, further reducing the material aroundthe access corridor that can obstruct imaging and or instrumentmanipulation. For example, unlike normal anterior retractor frames, theframe extends around less than half of the perimeter. The independentthird blade is also useful in better facilitating the positioning of thethird blade 214 in a different plane than the first and second blades114, 156, allowing the blade to more easily reach deeper along themedial side of the vertebra.

One example technique for performing a Lateral ALIF procedure to theL5-S1 disc space with the retractor assembly 2 is described hereafter byway of example. As noted, the patient is positioned on the table in thelateral decubitus position and appropriately secured using tape or othersuitable tools. Following standard surgical preparation, the disc spaceis localized using lateral fluoroscopy. A template is used to make skinmarkings to define the iliac crest, inferior endplate of L5, superiorendplate of S1, and midline. An oblique incision is made lateral to therectus and cephalad to the inguinal ligament and an alternating bluntscissor and finger dissection is used to enter the retroperitonealspace. Once the index finger is inside the space, a gentle sweepingmotion is used to palpate the left common iliac vessels and create aspace through which second retractor blade 156 of the second bladeassembly 12 may pass. Once a pathway to the disc space is created, thefirst (lateral) blade 156 is advanced through the retroperitoneal spaceand positioned medial to the descending common iliac vessels and lateralto the L5-S1 disc space with the distal end docked on the disc. (FIG.42). Prior to advancing the retractor blade, a light cable (not shown)may be engaged in the slot 165, or otherwise directed into the incision.The distal end of the blade 156 may then be anchored with the placementa bone anchor through one of the anchor channels 164 and into the Sivertebral body. Next, the first (cranial) retractor blade 114 may beguided down to the superior aspect of the disc space and below thedescending vessel bifurcation (FIG. 43). The distal end of the blade maybe anchored with the placement of a bone anchor through the anchorchannel 132 into the L5 body. The frame 8 may be assembled with a pairof carriages 16 advanced into the track 24 and moved to align with thecarriage markers 33, leaving the carriages in the unlockedconfiguration. The frame 8 is then centered around the incision with thelateral carriage marker oriented laterally and the cranial carriagemarker 33 oriented cranially. A rigid table mount, for example, an A-armmount (not shown) may then be coupled to the mount connect 34 to fix theposition of the frame. The first and second retractor assemblies 10, 12,may then be coupled to the frame by snapping the posts 108, 150 into theblade channel 60 of the blade holder 52 (FIG. 43). The position andorientation of the carriage/blade holder may be adjusted in any of the 5.degree. of freedom described above in order to engage the post with theblade holder. Once the blades 114, 156 are coupled to the blade holder52, the handle 106 may be turned to advance the locking cap 88 and lockeach of the carriages 16 as described above. With the main retractor 4in place, the offset or independent retractor 6 with is placed in themedial position. The third (medial) blade 214 may be advanced throughthe incision and positioned over the L5-S1 disc space. Because thepatient is in the lateral decubitus position the abdominal contents tendto fall away and the third blade 114 functions more to form a barrierand maintain tissue out of the corridor than to actually fully retracttissue. This both allows the third blade 214 to function effectivelywithout a fourth blade as is with other ALIF retractors and proceduresand facilitates advancement of the third blade 214 farther down alongthe side of the vertebral body where the forward hook of the distal end230 hook around the vertebrae and leverage against it to maintain goodposition as the blade 214 is angled down to increase the exposure. Thethird blade assembly is then rigidly fixed in position by attaching to arigid table mount, by way of example, an A-arm table mount via thecoupler 260. Once access to the disc space is achieved has beenachieved, the surgeon may proceed with disc space preparation andimplant placement.

With reference to FIGS. 46-47 there is depicted an alternateconfiguration of a retractor assembly 300. The retractor assembly 300 issimilar to the retractor assembly 2 in most respects, but is configuredfor use during standard or supine anterior access surgery. For example,the retractor assembly 30 utilizes four retractor blades rather thanthree. As shown, four second blade assemblies 12 are utilized andcoupled to four carriages 16 respectively. It should be appreciatedhowever that all four second blade assemblies 12 could be replaced withfour first blade assemblies 10, or any combination of first bladeassemblies 10 and second blade assemblies 12 could be used. Rather thana single piece, the frame 302 includes a first frame portion 304 and asecond frame portion 306. Each frame portion is approximately 180.degree. such that together they form a circle. The radius of the circlein the example show is approximately 12″ which provides enough room thatmultiple levels may be performed without moving the retractor frame. Theframe portions 304 and 306 are identical to the frame 8 previouslydescribed except for the radius and arc length as noted, and the firstframe portion 304 incudes two end openings 308 at the end of the track,and the second frame portion 306 includes two connectors 310 that engagein the openings to couple the first frame portion 302 and second frameportion 304 together.

The foregoing description illustrates and describes the processes,machines, manufactures, compositions of matter, and other teachings ofthe present disclosure. Additionally, the disclosure shows and describesonly certain embodiments of the processes, machines, manufactures,compositions of matter, and other teachings disclosed, but, as mentionedabove, it is to be understood that the teachings of the presentdisclosure are capable of use in various other combinations,modifications, and environments and is capable of changes ormodifications within the scope of the teachings as expressed herein,commensurate with the skill and/or knowledge of a person having ordinaryskill in the relevant art. It is to be understood that any givenelements of the disclosed embodiments of the invention may be embodiedin a single structure, a single step, a single substance, or the like.Similarly, a given element of the disclosed embodiment may be embodiedin multiple structures, steps, substances, or the like. The embodimentsdescribed hereinabove are further intended to explain certain best modesknown of practicing the devices, instruments, techniques, and otherteachings of the present disclosure and to enable others skilled in theart to utilize the teachings of the present disclosure in such, orother, embodiments and with the various modifications required by theparticular applications or uses. Accordingly, the devices, instruments,techniques, and other teachings of the present disclosure are notintended to limit the exact embodiments and examples disclosed herein.Any section headings herein are provided only for consistency with thesuggestions of 37 C.F.R. .sctn. 1.77 or otherwise to provideorganizational queues. These headings shall not limit or characterizethe invention(s) set forth herein.

1-40. (canceled)
 41. A method comprising: positioning a patient on atable in a lateral decubitus position; forming an incision in thepatient; accessing the patient's retroperitoneal space; advancing alateral retractor blade into the retroperitoneal space; advancing acranial retractor blade into the retroperitoneal space; advancing firstand second carriages into a track of an arcuate frame; disposing theframe proximate the incision; coupling a first rigid table mount to theframe; coupling a lateral retractor assembly to the frame by disposing alateral retractor post of the lateral retractor assembly in a bladeholder of the lateral carriage; coupling a cranial retractor assembly tothe frame by disposing a cranial retractor post of the cranial retractorassembly in a blade holder of the cranial carriage; through a corridordefined in part by the lateral retractor blade and the cranial retractorblade, preparing a target disc space; placing an implant in the targetdisc space; and closing the incision.
 42. The method of claim 41,further comprising: advancing a medial retractor blade into theretroperitoneal space; and using the medial blade to maintain abdominalcontents tissue out of a corridor defined in part by the lateralretractor blade and the cranial retractor blade.
 43. The method of claim42, further comprising: wherein the medial blade is used to maintainabdominal contents out of the corridor without retracting tissue withthe medial blade.
 44. The method of claim 42, further comprising:hooking a distal end hook of the medial blade on a vertebrae andleveraging against the vertebrae as the third blade is angled down toincrease exposure.
 45. The method of claim 42, further comprising:fixing the position of the medial blade to a second rigid table mountseparate from the first.
 46. The method of claim 41, wherein the targetdisc space is the patient's L5-S1 disc space.
 47. The method of claim46, further comprising: making a first skin marking on the patientdefining the patient's iliac crest; making a second skin marking on thepatient defining an inferior endplate of the patient's L5 vertebra;making a third skin marking on the patient defining a superior endplateof the patient's S1 bone; and making a third skin marking on the patientdefining a midline.
 48. The method of claim 46, further comprising:positioning the lateral retractor blade medial to one or more descendingcommon iliac vessels and lateral to the L5-S1 disc space.
 49. The methodof claim 46, further comprising: anchoring the lateral retractor bladeby placing a bone anchor through an anchor channel of the lateralretractor blade and into the S1 bone.
 50. The method of claim 46,further comprising: advancing the cranial retractor blade to a superioraspect of a target disc space and below a descending vessel bifurcation.51. The method of claim 46, further comprising: anchoring a distal endof the cranial retractor blade by placing a second bone anchor throughan anchor channel of the cranial retractor blade and into the L5vertebra.
 52. The method of claim 41, further comprising: securing thepatient in the lateral decubitus position using tape.
 53. The method ofclaim 41, wherein forming the incision includes: forming an obliqueincision lateral to a rectus muscle of the patient and cephalad to aninguinal ligament of the patient.
 54. The method of claim 41, whereindisposing the frame proximate the incision includes orienting the framesuch that a lateral carriage marker of the frame is oriented laterallyand a cranial carriage marker of the frame is oriented cranially
 55. Themethod of claim 41, wherein the lateral carriage is in an unlockedconfiguration while the lateral retractor post is disposed in the bladeholder of the lateral carriage; wherein the cranial carriage is in anunlocked configuration while the cranial retractor post is disposed inthe blade holder of the cranial carriage; and wherein the method furthercomprises: after coupling the lateral retractor assembly to the frame,locking the lateral carriage; and after coupling the cranial retractorassembly to the frame, locking the cranial carriage.
 56. A methodcomprising: performing a single-position lumber interbody fusion at anL5-S1 disc space of a patient in a lateral decubitus position, whereinperforming the single-position lumber interbody fusion includes:positioning the patient on a table in the lateral decubitus position;forming an incision in the patient; accessing the patient'sretroperitoneal space; advancing a lateral retractor blade into theretroperitoneal space; advancing a cranial retractor blade into theretroperitoneal space; advancing a lateral carriage and a cranialcarriage into a track of an arcuate frame; disposing the frame proximatethe incision; coupling a lateral retractor assembly to the frame bydisposing a lateral retractor post of the lateral retractor assembly ina blade holder of the lateral carriage; coupling a cranial retractorassembly to the frame by disposing a cranial retractor post of thecranial retractor assembly in a blade holder of the cranial carriage;through a corridor defined in part by the lateral retractor blade andthe cranial retractor blade, preparing a target disc space; placing animplant in the target disc space; and closing the incision.
 57. Themethod of claim 56, further comprising: positioning the lateralretractor blade medial to one or more descending common iliac vesselsand lateral to the L5-S1 disc space; anchoring the lateral retractorblade by placing a bone anchor through an anchor channel of the lateralretractor blade and into the S1 bone; advancing the cranial retractorblade to a superior aspect of a target disc space and below a descendingvessel bifurcation; and anchoring a distal end of the cranial retractorblade by placing a second bone anchor through an anchor channel of thecranial retractor blade and into the L5 vertebra.
 58. The method ofclaim 56, further comprising: advancing a medial retractor blade intothe retroperitoneal space; using the medial blade to maintain abdominalcontents tissue out of a corridor defined in part by the lateralretractor blade and the cranial retractor blade; fixing the position ofthe frame to a first mount; and fixing the position of the medial bladeto a second mount separate from the first mount.
 59. A methodcomprising: performing a single-position lumber interbody fusion at adisc space of a patient in a lateral decubitus position, whereinperforming the single-position lumber interbody fusion includes:positioning the patient on a table in the lateral decubitus position;forming an incision in the patient; accessing the patient'sretroperitoneal space; advancing a lateral retractor blade into theretroperitoneal space; advancing a cranial retractor blade into theretroperitoneal space; advancing a lateral carriage and a cranialcarriage into a track of an arcuate frame; disposing the frame proximatethe incision; coupling a lateral retractor assembly to the frame bydisposing a lateral retractor post of the lateral retractor assembly ina blade holder of the lateral carriage; coupling a cranial retractorassembly to the frame by disposing a cranial retractor post of thecranial retractor assembly in a blade holder of the cranial carriage;advancing a medial retractor blade into the retroperitoneal space; usingthe medial blade to maintain abdominal contents tissue out of a corridordefined in part by the lateral retractor blade and the cranial retractorblade; through a corridor defined in part by the lateral retractor bladeand the cranial retractor blade, preparing a target disc space; placingan implant in the target disc space; and closing the incision.
 60. Themethod of claim 59, further comprising: fixing the position of the frameto a first mount; and fixing the position of the medial blade to asecond mount separate from the first mount.